ABSTRACT

As the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is transmitted mainly through droplets, sneezes and aerosols, there is a high risk of transmission during dental procedures. This report describes measures that can be adopted by oral healthcare personnel to minimize the risk of cross-contamination in clinical practice during the current SARS-CoV-2 pandemic.

Second, it is crucial to avoid overcrowding in circulation areas and waiting rooms, since there is evidence that the close contact between susceptive individuals and infected individuals (being within about 1.8 m or within the room or care area of a confirmed COVID-19 case) increase the risk for SARS-CoV-2 infection (1111. Ghinai I, McPherson TD, Hunter JC, Kirking HL, Christiansen D, Joshi K, et al. First known person-to-person transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in the USA. Lancet [Internet]. 2020 Mar 13; Available from: http://www.ncbi.nlm.nih.gov/pubmed/32178768 http://www.ncbi.nlm.nih.gov/pubmed/32178... ). This may require an important change of habit in dental offices, where patients are often scheduled on a first-come, first-served basis, causing crowding. At this time, it is of fundamental importance that patients are scheduled by appointment, with a safety time frame between dental consultations, preventing contact or even proximity with other patients.

Third, the need for urgent dental care should be evaluated on a case-by-case basis and life- threatening cases should be admitted in a hospital. In case of urgent dental care, the main following measures targeted toward prevention by respiratory droplet and contact transmission should be adopted:

To assess suspected patients through their signs and symptoms, especially fever and cough (1212. Zhao D, Yao F, Wang L, Zheng L, Gao Y, Ye J, et al. A comparative study on the clinical features of COVID-19 pneumonia to other pneumonias. Clin Infect Dis [Internet]. 2020 Mar 12; Available from: http://www.ncbi.nlm.nih.gov/pubmed/32161968 http://www.ncbi.nlm.nih.gov/pubmed/32161... ). In these cases, dental procedures should be postponed, and health authorities should be notified. Symptomatic relief for patients with tooth pain and/or swelling could be performed with analgesics such as acetaminophen. Although it was hypothesized a potential interaction between ibuprofen use and SARS-CoV-2 (1313. Day M. Covid-19: ibuprofen should not be used for managing symptoms, say doctors and scientists. BMJ [Internet]. 2020;368:m1086. Available from: http://www.ncbi.nlm.nih.gov/pubmed/32184201 http://www.ncbi.nlm.nih.gov/pubmed/32184... ), there is no current evidence that this drug aggravates COVID-19 infection in any age group. Recently, the World Health Organization disclaimed there is contraindication for the use of ibuprofen in patients with COVID-19.

To clean hands with soap and water or hand rub with 70% ethanol or 70% isopropanol (1818. Centers for Disease Control and Prevention. CDC Statement for Healthcare Personnel on Hand Hygiene during the Response to the International Emergence of COVID-19 [Internet]. 2020 [cited 2020 Apr 9]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/hand-hygiene.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Finfection-control%2Fhcp-hand-sanitizer.html https://www.cdc.gov/coronavirus/2019-nco... ), before and after assistance. Avoid touching eyes, nose, or mouth with uncleaned hands. Although there are no current studies evaluating the effects of ethanol on SARS-CoV-2, previous studies have shown that hand rubs with 70% ethanol or 70% isopropanol are usually effective against enveloped viruses including SARS-CoV and MERS-CoV (1919. Kariwa H, Fujii N, Takashima I. Inactivation of SARS coronavirus by means of povidone-iodine, physical conditions and chemical reagents. Dermatology [Internet]. 2006;212 Suppl:119–23. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16490989 http://www.ncbi.nlm.nih.gov/pubmed/16490... ,2020. Kampf G. Efficacy of ethanol against viruses in hand disinfection. J Hosp Infect [Internet]. 2018 Apr;98(4):331–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/28882643 http://www.ncbi.nlm.nih.gov/pubmed/28882... ).

To use rubber dam isolation during dental procedures and avoid the use of ultrasonic and sonic scalers, air polishing, air-water syringe, air abrasion units, and rotary handpieces. In vitro study showed that the airborne material generated by using ultrasonic scaler can be spread for a distance of at least 20 cm from the operative site (2222. Harrel SK, Barnes JB, Rivera-Hidalgo F. Aerosol and splatter contamination from the operative site during ultrasonic scaling. J Am Dent Assoc [Internet]. 1998 Sep;129(9):1241–9. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0002817714662656 https://linkinghub.elsevier.com/retrieve... ). Furthermore, the potential for the spread of an pathogen via an invisible aerosol must be recognized and minimized or eliminated to the greatest extent feasible within a clinical situation (2323. Harrel SK, Molinari J. Aerosols and splatter in dentistry: a brief review of the literature and infection control implications. J Am Dent Assoc [Internet]. 2004 Apr;135(4):429–37. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15127864 http://www.ncbi.nlm.nih.gov/pubmed/15127... ). Importantly, it was shown that droplet nuclei can remain suspended in the air for up to 30 minutes (2424. Larato DC, Ruskin PF, Martin A, Delanko R. Effect of a dental air turbine drill on the bacterial counts in air. J Prosthet Dent [Internet]. 1966 Jul;16(4):758–65. Available from: https://linkinghub.elsevier.com/retrieve/pii/0022391366901570 https://linkinghub.elsevier.com/retrieve... ). Therefore, removing the mask before 30 minutes in this environment may increase the risk of contact with contaminated particles. Efficient removal of contaminated ambient air could include improvements in the general ventilation and the use of High-Volume Evacuator. To date, there is no evidence of clinical effectiveness of pre- and post-procedural rinse with antiseptic solutions for SARS-CoV-2.

For both suspected or confirmed COVID-19 cases requiring urgent dental care (e.g., abscess drainage), especially for those who will undergo procedures that generate aerosols, it is necessary, if possible, to leave them for the end of the service shift and promote terminal disinfection after care to avoid contaminating others.

To clean and disinfect environmental surfaces and patientcare equipment using hospital grade germicides (quaternary ammonium-based, phenol-based, and alcohol-based products), as the SARS-CoV-2 can survive for 72 hours on surfaces of stainless steel and plastic, 24 hours in cardboard and from 40 minutes to 2 hours 30 minutes in aerosolized form or in dust (2525. van Doremalen N, Bushmaker T, Morris D, Holbrook M, Gamble A, Williamson B, et al. Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1. N Engl J Med. 2020 Mar;NEJMc2004973.). Disinfection and sterilization of instruments should be performed using appropriate PPE and well-established techniques. Reinforce biosafety guidelines for auxiliary staff of dentists. It is important to keep an adequate time frame between consultations for a correct cleaning of the dental office structure.

To dispose the waste from dental procedures in specific packages for infected waste. These must be replaced when reaching 2/3 of their capacity or at least within 48 hours, or in compliance with the institution’s infection control committee protocols, since the inadequate disposal offers high risk to ecological and public health (2626. Muhamedagic B, Muhamedagic L, Masic I. Dental office waste - public health and ecological risk. Mater SocioMed. 2009;21(1):35–8.).

At this moment, it is important to recognize that controlling the spread of SARS-CoV-2 requires effort and oral health care providers may play an important role against this pandemic. Biosafety protocols and specific COVID-19- protective measures must be strictly followed in case of need of urgent dental care.

Disclaimer.

Authors hold sole responsibility for the views expressed in the manuscript, which may not necessarily reflect the opinion or policy of the RPSP/PAJPH or the Pan American Health Organization (PAHO).

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Day M. Covid-19: ibuprofen should not be used for managing symptoms, say doctors and scientists. BMJ [Internet]. 2020;368:m1086. Available from: http://www.ncbi.nlm.nih.gov/pubmed/32184201 » http://www.ncbi.nlm.nih.gov/pubmed/32184201